BENINGTON PRIMARY SCHOOL DATA COLLECTION SHEET

Please enter the information below and return to the school office.

Surname:		Legal Surname:		
Forename:		Middle Name		
Chosen name:		Gender		
Date of Birth:		Address including postcode

	

	

Please give details of all persons who you wish to be contacted in an emergency, placing them in the order that you wish for them to be contacted in an emergency. 

Priority	Name/Relationship	Home Address/Phone/Mobile	Work  Phone/Email

1

		Address – if different to child

Tel: 
Mobile
Email	
Tel: 
Email: 	
Does this person have Parental responsibility?                 Yes……….   No…………..
	
Does this person wish to be registered on Arbor?              Yes………      No………..

2		 Address if different to child

Tel: 
Mobile: 
Email	 Work

Tel: 
Email: 	
Does this person have Parental responsibility?                 Yes……….   No…………..
	
Does this person wish to be registered on Arbor?             Yes………      No………..

3
		Address

Tel:
Mobile:
Email 	

Tel:
Email:	
Does this person have Parental responsibility?                 Yes……….   No…………..
	
Does this person wish to be registered on Arbor?             Yes………      No………..

Medical Information	
Medical Practice	Address	Telephone Number	

Does your child suffer from	Allergies – please specify

	
	Asthma – if so are they under the asthma clinic

	Fits

	Nose bleeds

	Sight problems – do they wear glasses, if so all the time or for specific lessons

	Hearing problems – do they have a hearing aid

	
	Speech difficulties – are they receiving speech therapy

Are they having any continuous medical treatment?	

Have they had any serious illnesses or accidents?	

Do they need to keep medication in school? 
If so you’ll need to complete a form. 	

Injections	Please indicate  Y / N as appropriate	
MMR		
HIB		
Polio		
Whooping Cough		
Tetanus		
Diphtheria		

Is there any other information you think we should know about? Disabilities, special diet etc

	

General Information

Ethnicity (Optional)	

	Religion: (Optional)	

Home Language:	

First Language:	

Country of Birth:	

Nationality:	

To comply with the new General Data Protection Regulations (GDPR), we need your permission to hold this personal information whilst your child attends Benington Primary School. The data will be used and processed in accordance with the Privacy Notices which are available on the School website.

	
Signature:

	Date:

	

If any circumstances change please let the office know ASAP, thank you.